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Insurance Certificates 2024/25 Dychelon LLCINSURANCE REVIEW Cu �CU ( Al IFOR\IA - RE: Short -form agreement with Dychelon, LLC to conduct SB553 Workplace Violence Prevention assessment and provide training. Please list the Contracting Party / Vendor Name, type of agreement to be executed, including any change orders or amendments, and the type of services to be provided. Make sure to list any related Project No. and Project Name. Insurance certificates required per the Agreement: ACCORD Certificate dated 10-days prior or less 11 /8/2024 enter ACCORD issue date Commercial General Liability Insurance: ❑✓ $1,000,000 per occurrence/$2,000,000 aggregate OR $2,000,000 per occurrence/$4,000,000 aggregate Additional Insured Endorsement naming City of La Quinta Primary and Non -Contributory Endorsement Automobile Liability: F,—/]$1,000,000 combined single limit for bodily injury and property damage. Workers' Compensation: ❑ Statutory Limits / Employer's Liability $1,000,000 per accident or disease ❑ Workers' Compensation Endorsement with Waiver of Subrogation ❑ Sole Proprietor Professional Liability (Errors and Omissions): ❑✓ Errors and Omissions Liability insurance with a limit of not less than $1,000,000 per claim Cyber Liability/Technology Errors and Omissions Liability Insurance: F-1$1,000,000 per occurrence/loss Other: Approved by: List other insurance types such as - molestation, harassment, etc. Oscar Mojica Date: 12/2/2024 ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 11/08/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Joseph Guidi gFA Micheli Region 1 PHONE 951) 677-6200 A/C, No, Ext : (A/C, No): ADDRESS: Jguidi@siainc.net 41870 Kalmia St Ste 100 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Hlscox 10200 Murrieta CA 92562 INSURED INSURER B : Progressive 24260 INSURER C : Hiscox 10200 Albert Cobos dba Dychelon LLC INSURER D : 14062 WOODLAWN AVE INSURER E : INSURER F : TUSTIN CA 92780 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER YL;" (MMIDD/FL)LIL;Y LA (MM/DD/YYYY) LIMITS )C COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE FKI OCCUR PREMISES (Ea occurrence) $ 100,00 MED EXP (Any one person) $ 5,000 PERSONAL a ADV INJURY $ 1,000,000 A Y Y P1007120015 11/6/2024 11/6/2025 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- POLICY ❑ PRO ❑ LOC PRODUCTS - COMP/OP AGG $ OTH ER: $ AUTOMOBILE LIABILITY (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ ANY AUTO B OWNED SCHEDULED AUTOS ONLY /► AUTOS Y Y 987960399 10/14/2024 04/14/2025 /► BODILY INJURY (Per accident) $ HIRED ��// NON -OWNED AUTOS ONLY 1K AUTOS ONLY �/ K (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ER OTH- STATUTE I ER E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? N / A E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ Each Occurrence 1,000,000 C Professional Liability Y Y P1007109335 11/6/2024 11/6/2025 General Aggregate DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is named as Additional Insured when required by written contract. Waiver of Subrogation applies in favor of the certificate holder with required by written contract. GL policy is considered primary non-contributory. All terms, conditions, limitations and exclusions apply as per policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of La Quinta THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Human Resources ACCORDANCE WITH THE POLICY PROVISIONS. 78495 Calle Tampico La Quinta, CA 92253 AUTHORIZED REPRESENTATIVE © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Aew H I SCOX HISCOX INSURANCE COMPANY INC. (A Stock Company) encourage courage- 104 South Michigan Avenue, Suite 600, Chicago, Illinois 60603 Commercial General Liability Declarations In return for the payment of the premium, and subject to all the terms of this Policy, we agree with you to provide the insurance as stated in this Policy. Declaration effective from Policy No.: Renewal of: Named Insured: Address: Email Address: Policy period: Form of Business: Each Occurrence Limit: November 6, 2024 P100.712.001.6 I P100.712.001.5 I Dychelon LLC 23421 Rouge River Lane Murrieta, CA 92562 alcobosmicc6@gmail.com From: I November 6, 2024 To: I November 6, 2025 At 12:01 A.M. (Standard Time) at the address shown above. Damage to Premises Rented to You Limit: Medical Expense Limit: Personal & Advertising Injury Limit: General Aggregate Limit: Products/Completed Operations Aggregate Limit: Supplemental Business Personal Property Floater Coverage Limit: Limited Liability Company $1,000,000 $100,000 Any one premises $5,000 Any one person $1,000,000 Any one person or organization $2,000,000 Products -completed operations are subject to the General Aggregate Limit $0 Supplemental Business Personal Property Floater Not Applicable Coverage Deductible: All Premises You Own, Rent or Occupy Premises Number: 1 Address: 23421 Rouge River Lane Murrieta, CA 92562 Total Premium: 416.00 Attachments: See attached Forms and Endorsements Schedule. CGL D001 10 18 Includes copyrighted material of Insurance Services Office, Inc., with Page 1 its permission. @ ISO Properties, Inc., 2000 Aew H I SCOX HISCOX INSURANCE COMPANY INC. (A Stock Company) encourage courage- 104 South Michigan Avenue, Suite 600, Chicago, Illinois 60603 IN WITNESS WHEREOF, the Insurer indicated above has caused this Policy to be signed by its President and Secretary, but this Policy shall not be effective unless also signed by the Insurer's duly authorized representative. President s4--1a- Secretary Authorized Representative CGL D001 10 18 Includes copyrighted material of Insurance Services Office, Inc., with Page 2 its permission. © ISO Properties, Inc., 2000 Aew H I SCOX HISCOX INSURANCE COMPANY INC. (A Stock Company) encourage courage- 104 South Michigan Avenue, Suite 600, Chicago, Illinois 60603 Forms and Endorsements Schedule Forms and Endorsements made part of this policy at time of issue: CGL D001 10 18 - Commercial General Liability Declarations INT D001 01 10 - Forms and Endorsements Schedule CG 00 01 12 07 - General Liability Coverage Form CGL E5401 CW (03/10) - Definition of Employee CGL E5403 CW (03/10) - Notice Information CGL E5404 CW (03/10) - Exclusion - Personal Information CGL E5407 CW (03/10) - Exclusion - Professional Services CGL E5408 CW (03/10) - Cancellation Provision (14 Day Full Refund) CGL E5409 CW (03/10) - Right and Duty to Select Defense Counsel CGL E5421 CW (02/14) - Additional Insured - Automatic Status IL 00 17 11 98 - Common Policy Conditions IL 00 21 09 08 - Nuclear Energy Liability Exclusion Endorsement (Broad Form) CG 00 68 05 09 - Recording and Distribution of Material or Information in Violation of Law Exclusion CG 21 41 11 85 - Exclusion - Intercompany Products Suits CG 04 37 12 04 - Electronic Data Liability CGL E2221 CW (10/23) - Exclusion - Privacy and Cyber Incidents IL 02 70 09 08 - California Changes - Cancellation and Nonrenewal CG 32 34 01 05 - California Changes CGL E5581 CW (03/16) - Primary and Noncontributory - Other Insurance Condition CGL E5402 CW (03/10) - Modified Waiver of Transfer of Rights of Recovery Against Others To Us CG 21 73 01 15 - Exclusion Of Certified Acts Of Terrorism CGL E5405 CW (03/10) - Exclusion - Damage to Primary Residence CGL E1954 CW (05/20) - Asbestos - Exclusion CGL E1975 CW (05/20) - Limitation of Coverage to Business Operations CG 21 32 05 09 - Communicable Disease Exclusion CGL E2227 CW (03/23) - Amended War Exclusion CGL E2225 CW (01/23) - Cannabis Exclusion CGL E1952 CW (05/20) - Exclusion - Anti -Stacking INT N003 CW (01/19) - Policyholder Notice Electronic Delivery INT N001 CW (01/09) - Economic And Trade Sanctions Policyholder Notice INT D001 01 10 Page 1 of 1 40 HISCOX encourage courage® Endorsements 40 HISCOX Policy Number: P100.712.001.6 Named Insured: Dychelon LLC Endorsement Number: 7 Endorsement Effective: 11/06/2024 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - AUTOMATIC STATUS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any per- son(s) or organization(s) for whom you are performing operations or leasing a premises when you and such person(s) or organiza- tion(s) have agreed in writing in a contract or agreement that such person(s) or organiza- tion(s) be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to lia- bility for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing opera- tions; or 2. In connection with your premises owned by or rented to you. A person's or organization's status as an addi- tional insured under this endorsement ends when your operations or lease agreement for that additional insured are completed. CGL E5421 CW (02/14) Includes copyrighted material of Insurance Services Office, Inc., with its Page 1 of 1 permission. 40 HISCOX Policy Number: P100.712.001.6 Named Insured: Dychelon LLC Endorsement Number: 16 Endorsement Effective: 11/06/2024 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy, pro- vided: 1. you have agreed in a written contract or agreement to add such additional insured to a policy providing the type of coverage af- forded by this policy; and 2. you have agreed in a written contract or agreement with such additional insured that this insurance would be primary and would not seek contribution from any other insur- ance available to the additional insured. CGL E5581 CW (03/16) Includes copyrighted material of Page 1 of 1 Insurance Services Office, Inc., with its permission Declaration of Sole Proprietor DECLARATION AND ADDENDUM TO ALL CONTRACTS AWARDED TO DYCHELON LLC Individual or Organization Name I declare for the purpose of inducing the City of La Quinta to go forward with any contracts awarded to DYCHELON LLC as follows: I am the authorized representative of DYCHELON LLC an independent contractor for the purposes of the California Workers' Compensation and Labor laws. This organization will hire no employees other than the parents, spouses, or children of its board members for work required for any bid or contract awarded to DYCHELON LLC . All worked required will be performed personally and solely by me, other board members of the organization, their parents, spouses or children, or persons who perform voluntary service without pay to the organization. If, however, the organization shall ever hire employees to perform this contract or any portion thereof, the organization shall obtain Workers' Compensation Insurance and provide proof of Workers' Compensation Insurance coverage to the City of La Quinta. If the organization shall ever hire a subcontractor to perform this contract or any portion thereof, and the subcontractor has employees, then the organization shall require its subcontractor to obtain Workers' Compensation Insurance Coverage, or the organization shall obtain Workers' Compensation Coverage for that subcontractor's employees. This document constitutes a declaration by the organization against its financial interest, relative to any claims it should assert under the California Workers' Compensation and/or Labor laws against City of La Quinta relating to any bid or contract awarded to DYCHELON LLC The organization will defend, indemnify and hold harmless the City of La Quinta from any and all claims and liability, including Workers' Compensation claims and liability that may be asserted or established by any party in the event the organization hires an employee in violation of this addendum, and the organization will further indemnify the City of La Quinta for all damages the City of La Quinta thereby suffers. I agree that these declarations shall constitute an addendum to any bid or contracts awarded to 10-24-24 Date Authorized Representative Declaration Regarding California Workers' Compensation You are required to complete this form because you have not filed a certificate regarding workers' compensation insurance with City of La Quinta. California law requires all employers to carry workers' compensation insurance, even if they have only one employee. If you do not know whether you are required to carry workers' compensation insurance, find out by contacting the California Department of Industrial Relations ("DIR"). Information is also available on the DIR's website at http://www.dir.ca.gov. You should also consult with your attorney, insurance agent or broker, or carrier regarding the specifics of your situation and your options. If you are subject to the Workers' Compensation Laws of California, you must promptly file a certificate of Workers' Compensation Insurance with City of La Quinta. If you have a certificate of self-insurance from the DIR, you must file that certificate with City of La Quinta. When completing this form, remember that the term "employee" includes clerical persons as well as any other persons employed by your company including drivers. ACKNOWLEDGMENT AC (initial) California Labor Code § 3700 requires employers to carry workers' compensation insurance or to obtain a certificate from the Director of Industrial Relations demonstrating that the employer is self -insured. California Labor Code § 3700.5 makes it a criminal offense for an employer to fail to secure compensation as required by the workers' compensation provisions of the Labor Code. Violation of Labor Code § 3700 is punishable by a fine of up to $10,000 and/or imprisonment for up to one year. AC (initial) California Labor Code § 3710.1 provides that where an employer fails to provide compensation required under § 3700, the Director of the Department of Industrial Relations shall issue a stop order, prohibiting the employer from using employee labor until such time as the employer complies with the provisions of § 3700. Labor Code § 3710.2 makes it a criminal offense to disregard such stop orders. AC (initial) I acknowledge that if evidence is found that contradicts this declaration, City of La Quinta will promptly notify all relevant state agencies to ensure full insurance compliance required by Workers' Compensation Laws of California. AC (initial) I understand that California Labor Code § 3700 et seq. requires employers to provide workers' compensation insurance coverage for any employees of my business. I hereby warrant that this business is exempt from the California Labor Code provisions regarding workers' compensation insurance because it has no employees. AC (initial) I agree to hold City of La Quinta and its officers, officials, employees, and agents harmless for loss or liability which may arise from the failure of my business to comply with the laws of the State of California regarding workers' compensation insurance. AC (initial) If I hire employees in the future, I will immediately notify City of La Quinta and provide a certified Workers' Compensation certificate to the City. CERTIFICATION (we) certify under penalty of perjury, under the laws of the State of California, that I (we) have read and understood the above stated requirements regarding Workers' Compensation and that I(we) am (are) in compliance. I(we) certify that the forgoing is true and correct. Executed this 24 day of OCTOBER 2024 at TUSTIN ,California Signature of Declarant ALBERT COBOS Print Name of Declarant DYCHELON LLC Print Name of Company